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STATE OF NEBRASKA
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<br />WHEN ;THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DA1'E OP ISSUANCE
<br />12/13/2423
<br />LINCOLN, NEBRASKA
<br />8
<br />202.402743
<br />aro
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />GEDENT'8 NAME (First, Middle, Last, Suffix)
<br />erfiyn Joan Menke
<br />CERTIFICATE OF DEATH
<br />4 GIN AND:STATE OR:TERRITORY, OR fOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7;SOCIAt SEIrURITYNUMBER'
<br />508667179
<br />TSC AGE - cast•Btrthday>
<br />(Yrs.)
<br />8b.' FACtLITY-NAME (twnot institution, give street and number)
<br />2410 Brahma
<br />8c. OIT OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68841
<br />Sa. RESIDENCE -STATE
<br />Nebraska
<br />Btl sSTREET AND NUMBER
<br />2410 Brahma
<br />913. COUNTY
<br />Hall
<br />74
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />1 MOS.
<br />DAYS
<br />Ba,. PLACE OF'DEATH
<br />HOSPITAL
<br />.1-1 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />10a':MARfTA( STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />1t .:FATHERS*ItlAME (F#req
<br />tarry Janulewicz
<br />Middle, Last, Suffix)
<br />13..EVE0IN t).$ ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) NO
<br />15, METHOD OF DISPOSITION
<br />Buftal ❑ Don(tion
<br />I,:J Cremation Entombment
<br />O Retnovar ❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 161830
<br />3. DATE OF DEATH (Mon Day Y8)
<br />December 3, 2023
<br />8. DATE OF, BIRTH (M0., Day,
<br />OTHER 0 Nursing Homs/LTC
<br />Ea Decedent's Monte
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9t. ZIP CODE
<br />68801
<br />'itlb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden=n
<br />Bradley C Menke
<br />112 MOTHER'S -NAME (First, Middle, Maiden
<br />Blanche Stanczyk
<br />14a. INFORMANT -NAME
<br />Bradley C Menke
<br />18a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />17a. FtNERAI HOME NAME AND MA LING ADDRESS (Street, City or TowikState)
<br />Curran Ftitlerat0:)aapel, 3005 S. Locust St., Grand Island, Nebraska
<br />18b. LICENSE NO.
<br />1092
<br />CITYI TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />. tNSIpE Oi' ? UIdtTS
<br />} fEs
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />18c. DATE (Mo., Day,: Yr.) j•
<br />December8, 2023
<br />STATE
<br />Nebraska
<br />1?b, ZipCl
<br />68801
<br />IL PART I. Enter the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on line. Add addRloaal lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAWifi'nal a) Undetermined Natural Causes
<br />Maltase or condition feauairtg ...
<br />in;deaMl
<br />Soquentiaily get: conditions, if
<br />aaT, leading tothe cause listed
<br />DUE TO, OR A CONSEQUENCE OF:
<br />b)',
<br />F.dtlr the UNDF.#ILyiNG CAUSE
<br />(die6aw or Injury that frr#iated
<br />the events resuking death)
<br />t.A$T
<br />in
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE INTERI
<br />onset to death
<br />Urikn wn
<br />AL
<br />18, PART (( OTHERSIGNI:FICANT;CONDITIONS-Conditions contributing to the dttath but not fbsu(tin
<br />Atrlaf )~Ibrillab ln, high blood pressure.
<br />20. (F FEMALE::
<br />Not pregnant wbatn part
<br />Pregnantitttme of dni.O. '
<br />1:1440.4faffbeftt.:butPfeghent within 42 days of death
<br />0 Not pregnant, but pregnant 41 days to 1 year before death
<br />0r� unknown 6regnittH wahin the P4.t year
<br />a'::DATE
<br />INJURY (Ma, Day, Yr.)
<br />22d.INJURY AT WORK?
<br />❑YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural © Homicide
<br />❑ Accident ❑ Pending inv4stIgatlon
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />in the underlying cause given in PART I.
<br />2.113,1F:. TRANSPORTATION
<br />❑ Onver/operator
<br />❑ Passenger
<br />❑ pedestrian
<br />❑ Other (Spec
<br />22c. PLACE OF INJURY.At home
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22l LOCATI(N'OP (NJUP(' STREET& NUMBER, APT.NO.
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />23b DATE SIGNED (Mo., Day, Yr.)
<br />CITYITOW N'
<br />23c. TIME OF DEATH
<br />TON, ii f of my knowledge, death occurred at the time, data and place
<br />'And due to the`aauseis) stated. (Signature and Title)
<br />o°.
<br />C
<br />E
<br />wg�
<br />INJURY
<br />19. WAS'MEDIGAi: EXAMINER'.
<br />OR CORONER CONTACTED?
<br />❑ YES I NO
<br />21c. WAS AN AUTt3FSY PERP
<br />❑ YES J NQ
<br />21d. WERE AUTOPSYPINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES [} NO
<br />farm, street, factory, office building, cons
<br />STATE
<br />P COO
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />December 6, 2023
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />December 3.
<br />24b. TIME OF DEATH
<br />Unknown
<br />2023 07:40 Ptli
<br />2M. On me bells of examination and/or investigation. In my opinion daa'fit ohfurrsa at
<br />teams- date and place and due to the cause(s) stated. (Signature end Tea) . ..
<br />Dave Medlin, Hall County Attorney
<br />2 010TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />•YES ',NO ] PROBABLY ® UNKNOWN ❑ YES • ®NO
<br />2i.•NAME, TITLE` 1b,A CRESS OF CERTIFIER (Type or Print
<br />av0 IN16clt'n, Halt County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?:..'
<br />Not Applicable if 26a is NO ❑YES
<br />28b. DATE FILED BY REGISTRAF
<br />December 12, 2023 .:
<br />o., D
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